To begin your journey we will explore how you think, feel and react through this quick survey. If you are interested in a consult, please take this survey to guide me in what best suits your needs. Name * First Name Last Name Email * Phone * (###) ### #### Is your body type thin? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you often worry that you "can't do it right"? Strongly Disagree Disagree Neutral Agree Strongly Agree Are you a perfectionist in some areas of your life but not all? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you like expressing yourself in long detailed scenarios? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you judge others easily? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you always have insomnia & are always analyizing what might happen next before sleep? Strongly Disagree Disagree Neutral Agree Strongly Agree Did you have a critical parent? Strongly Disagree Disagree Neutral Agree Strongly Agree Are you always meeting the needs of others and not your own needs? Strongly Disagree Disagree Neutral Agree Strongly Agree In childhood did you ever reverse parent or take care of siblings? Strongly Disagree Disagree Neutral Agree Strongly Agree Are you afraid of being rejected & may even reject others before they can reject you? Strongly Disagree Disagree Neutral Agree Strongly Agree When angry because others are not meeting your needs, do you explode outwardly or become the martyr? Strongly Disagree Disagree Neutral Agree Strongly Agree Are you an extrovert? Strongly Disagree Disagree Neutral Agree Strongly Agree Have you ever had an addiction created by wanting to belong? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you merge with others, sensing what they need? Strongly Disagree Disagree Neutral Agree Strongly Agree Are you a workaholic? Strongly Disagree Disagree Neutral Agree Strongly Agree Are you great at organizing and multitasking? Strongly Disagree Disagree Neutral Agree Strongly Agree Is your identity & drive to perform, based on what your parents expected of you; ie., good at business, sports, grades, socialite? Strongly Disagree Disagree Neutral Agree Strongly Agree When involved in a project is your feeling , “just get it done” without much compassion for others? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you have periods of overwhelmed where you sit on the sofa confused rather than being on the move? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you find yourself helping others to feel hopeful or motivated? Strongly Disagree Disagree Neutral Agree Strongly Agree Do others see you as a loving, caring person? Strongly Disagree Disagree Neutral Agree Strongly Agree Have you ever had long periods of depression? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you have times when you feel unworthy? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you some times feel that there is something inside of you that wants to come out? Strongly Disagree Disagree Neutral Agree Strongly Agree Did you have a parent who was mean or abusive (physical, emotional, verbal)? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you have an artistic side (widely defined)? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you have difficulty feeling & understanding what others are feeling? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you stay in your head thinking most of the Time? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you do loving things but don't really feel the love? Strongly Disagree Disagree Neutral Agree Strongly Agree Have you been able to really connect with a partner in an intimate relationship? Strongly Disagree Disagree Neutral Agree Strongly Agree Did you have a parent who you experience as dominating, manipulative? Strongly Disagree Disagree Neutral Agree Strongly Agree When stressed do you ever go to an addictive behavior? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you find yourself panicked over what might happen next-uncertainty? Strongly Disagree Disagree Neutral Agree Strongly Agree Are you able to anticipate what people & systems might work out? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you feel the need to protect family from the unsafe world? Strongly Disagree Disagree Neutral Agree Strongly Agree Are you good at the details of interior design? Strongly Disagree Disagree Neutral Agree Strongly Agree Are you hyperactive? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you like to rebel against rules & systems? Strongly Disagree Disagree Neutral Agree Strongly Agree Have you ever had an addiction that allows you to ground your energy or escape from the feeling of overwhelming responsibility? Strongly Disagree Disagree Neutral Agree Strongly Agree Are you “on” entertaining people most of the time but drop into criticism of self and others when stressed? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you make up stories or lie to others to meet your needs? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you like to be the boss? Strongly Disagree Disagree Neutral Agree Strongly Agree Are you a visionary? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you get angry/maybe want revenge when people or situations take control away from you? Strongly Disagree Disagree Neutral Agree Strongly Agree Have you ever had an addiction? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you go to a “cave” to pout & stay away from others to regain control when you feel stressed? Strongly Disagree Disagree Neutral Agree Strongly Agree Are you a CEO or own your business? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you dislike making decisions? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you merge with others and let them guide you? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you dislike conflict & avoid it when possible? Strongly Disagree Disagree Neutral Agree Strongly Agree Are you in your head a lot, letting life just flow by? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you have difficulty setting boundaries? Strongly Disagree Disagree Neutral Agree Strongly Agree Do others see you as sweet, good at counseling &/or a peacemaker? Strongly Disagree Disagree Neutral Agree Strongly Agree What has been your job or profession? Thank you! Sandra will review your responses and contact you to begin.